Laurie Jacobs, MD, Geriatrician, Chairman of the Department of Internal Medicine at Hackensack Meridian School of Medicine and Hackensack University Medical Center, talks about the possibility of COVID-19 causing hearing loss.
Here in the tri-state area, I know COVID hit very fast and hard. What were you seeing in terms of acute cases?
JACOBS: Our first case came in March 2 for about 10 days. That was the only patient. But he was very sick. Then, more and more patients appeared at the emergency room and calling their doctors in the ambulatory settings. The first number of patients were not that ill, but everybody was so concerned and frightened that they came for care. As time went on, about two to three weeks later, more and more patients had respiratory failure and needed intensive care. It was then we learned the sequence of the virus, which first is the viral phase, like when you have the flu and you’re coughing and feel achy and ill and have a fever. Then, you either recover or go on to have what we call the inflammatory phase. That’s often associated with respiratory failure. The numbers grew, peaked, and then receded down to a very low level in the state.
What kind of symptoms are you seeing now in some of these patients that had very serious COVID?
JACOBS: First of all, there are certain people who are at risk for COVID, and those same people may be the ones who have a more difficult time afterwards in the healing process. It’s not so clear because there’s not a lot of literature and experience yet. As we go along, we’re closely observing and trying to figure out what’s going on. But the risk factors have been talked about a great deal – obesity, hypertension, heart disease, diabetes, immune suppression. Those are the patients who tended to be more at risk for COVID and may have had a more difficult time. We think there are other risk factors for having a more difficult time and for having COVID symptoms that remain, but they are yet to be elucidated. People have talked about blood type. I don’t think that’s panned out entirely. There may be genetic or other underlying risk factors. We’re not really sure. But what seems to appear is that several patients who had mild COVID do recover within a month or so. Their complaints after their course were that they were terribly fatigued. But most of them recover fully. People with more severe disease sometimes go on to have symptoms. I would say maybe 40% to 50% have some symptoms from our studies within a month. Then it declines from there, but there’s a significant percent that have persistent symptoms. The so-called long-haulers have put online lists of symptoms that they are experiencing. What needs to be a bit separated is which are the symptoms related to COVID and which are the symptoms related to being in a hospital, perhaps on a respirator, where you’re not mobile? After being released, you may have remaining shortness of breath, muscle aches, etc… Some of those symptoms are not surprising and related to the course of care in a long illness. But there are many other symptoms that we’re seeing that we believe are related to COVID and not symptoms of an acute infection, although we’re all concerned that your immunity wanes, and you could get an acute infection again. But they’re not presenting with fever, cough, and the symptoms they had in the beginning. They’re presenting with continued cough, but more this terrible fatigue, shortness of breath, and then a whole host of neurologic symptoms, some of which are related to the peripheral nervous system, and some of which are related to your brain. Some of them say they have a foggy brain, and they’re just not thinking right. Others have symptoms related to nerve problems like muscle function and complain of weakness. Then there are a whole group of people who have disorders related to clotting. We’ve seen blood clotting or thrombosis at a proportion that’s way higher than with other acute illnesses or infections. Clotting can cause not only a swollen arm or swollen leg, but a stroke or heart attack or clot in your lung that causes sudden chest pain and shortness of breath. Then there are other symptoms that people complain of that we haven’t quite seen enough of or understand. A few people have complained of hair loss, but that happens often with stress from any illness. So, I don’t know if that’s a COVID symptom or just an acute illness symptom. Some people have had some skin problems, but again, we’re not sure that’s COVID or not. Then there are a whole bunch of people who have muscle aches, and so that may be related to the fatigue. The third big group are people who have continuing lung or cardiac problems. There was a recent study that just came out that indicated that even patients with no symptoms had abnormalities on an MRI done of their heart. It looks like there’s some muscle dysfunction of the heart, and the heart is inflamed on biopsies that they’ve taken. Some people present with symptoms of heart failure, shortness of breath, swelling. But it may be that everyone who had COVID might have some level of abnormality, that they have no symptoms. Maybe it will all go away. We don’t know. The other group of heart symptoms are sometimes heart rhythm problems, so that they have episodes of being dizzy or feeling like they’re going to pass out. It might be due to heart rhythm issues. All of these may be inflammatory, just like that second phase of COVID. Right now, everybody’s evaluating them and treating them as if these symptoms happen from any cause and following standard treatment. But the issue will come up, should we be using anti-inflammatory drugs, just like we do in the inflammatory stage of acute COVID? No one knows, but a lot of research is going on in this area.
How do you go about helping the patients who are recovering from this potentially long list of symptoms?
JACOBS: Well, I haven’t even talked about behavioral health issues which may be related to COVID or to being afraid for your family or being home and isolated. The first thing we do is take a very careful history. When did they have the disease? How severe was the disease? What were the treatments they received? And what is their baseline medical status? If it fits into one of those syndromes, for example, we’re concerned about clotting, we’re going to treat them with drugs that prevent clotting, anticoagulants. The patients who appear to have heart failure or a heart rhythm abnormality, we have several cardiac groups here that are evaluating those patients, and they’ve been collecting data since the beginning. So not only are we providing clinical care, but we’re trying to study and discern what’s going on and contribute to the literature. Any of the drugs that are used for acute COVID may not be appropriate at this point. They’re really treatments either for the inflammatory phase or for the particular problem. Some of the symptoms seem to get better over time, and some seem to persist like the lack of taste, although a lot of people don’t have that. If you have that, that was an early kind of identifying symptom for COVID. About 30% have that continuing. And of that group, some get better, and some don’t. Nobody has a big enough sample to know what percentage. That has been seen in other viral illnesses.
We’re talking to a patient tomorrow who had hearing loss. Is that a concerning symptom?
JACOBS: I would presume it’s probably a neurologic manifestation. I have been reading the literature along with looking at what our patients present with, and that is infrequent. I’ve seen very few patients complain of hearing loss. But we don’t know everything about this yet. It may be that people don’t attribute it to COVID, so they’re not presenting saying, I had COVID. Do you think it’s related? Not only are physicians and clinical programs collecting data, but patients themselves are. There’s an app for COVID where they’re asking for people to report symptoms. There’s a large study that’s sponsored by social media that collected data on symptoms. The problem with those studies is they don’t carefully define, were they PCR positive? What date did things start? What treatments did you get? What sequence, and what time? And you need all that information to understand what’s going on. It’s not enough to just say, this many people have a cough, and this many people have shortness of breath. We need to understand all the factors surrounding those symptoms.
Why is it important for the research to continue on all these symptoms?
JACOBS: This is a worldwide pandemic, and it’s involving hundreds of thousands of Americans. It may, in fact, lead to disability in some circumstances. I’ve been invited to present to Social Security Administration on the implications for disability for Americans and also for disabled Americans. Are they more at risk? In some circumstances, yes, and in some circumstances, no. So, that’s a two-part question. I did a small study here over a month, and the number of patients who had not yet returned to work was notable. That has big implications for our economy, for disability, for families. Not only do we want to help people get well as best we can, we need to understand the course so people can plan for their care and plan for their lives. Prior pandemics have had return peaks. No one really understands why it goes quiescent, but the flu in 1918, 1919 had three peaks. It went away and everybody thought they were OK, and then it came back. And honestly, what they did is all we’re doing: wearing masks and trying to be socially distant. That’s all they had then, and we haven’t advanced that much. Until we have a vaccine, we have no other method to prevent communication of COVID. So, if it comes back, the only way we can control it are these physical methods of preventing infection.
Can you tell a little bit about the center that was formed and who’s involved and why?
JACOBS: We formed a center because a lot of people were calling back to say, I have this problem, and a lot of the community physicians hadn’t actually treated patients with COVID. Their offices pretty much closed down. Everyone was afraid during the pandemic to come out because they might get it. They started getting telemedicine care. But nonetheless, here at Hackensack, almost all of the internists came and worked with us in the hospital because there were so many patients, and so they all got experience. We set up a center with several of the experienced internists. The procedure is that there’s an intake and a video call at first to find out what their needs are. If their need is purely behavioral health, they don’t have to come in and see the internist. Otherwise, we like them to be seen by the internist and then, if need be, referred to the specialist. We’ve chosen people who are all doing research on the COVID syndromes. We have neurologists, cardiologists, pulmonologists, psychiatrists, and people dealing with clotting. We have all of these physicians, but it’s virtual. So, at first you have a virtual visit and then an in-person visit. You can be referred at any one of those points to our physicians. Most of this is in Bergen County, but we have the plan to have it across the entire state of New Jersey. We’ve identified the practices. It’s just that the majority of patients were here in the New York, New Jersey metropolitan area.
Is there anything that you would like people to know?
JACOBS: I think that patients should stay alert to the news. There’s a lot of information on the Internet, but not all of it is true. I think the CDC website has a tremendous amount of information for the public on symptoms and referral sources. So, it’s important to check the veracity of what you’re reading. People come in with all kinds of ideas about medicines and other things. And of course, there are people who have taken experimental medicines and had bad outcomes. So, if you have something, come and seek care. And in my opinion, if somebody has a symptom and I can’t explain it, it doesn’t mean they don’t have it. We just have more to learn and we’re trying to work on that.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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